Facilitators Associated With Building and Sustaining Therapeutic Alliance in Advanced Pediatric Cancer

• Type of Material: Article
• Authors: Erica C Kaye, St Jude Children’s Research Hospital; Sarah Rockwell, Emory University; Cameka Woods, St Jude Children’s Research Hospital; Monica E Lemmon, Duke University; Karen Andes, Emory University; Justin N Baker, St Jude Children’s Research Hospital; Jennifer W Mack, Dana-Farber Cancer Institute
• Language: English
• Date: 2021-08-20
• Publisher: AMER MEDICAL ASSOC
• Publication Version: Final Published Version
• Copyright Statement: 2021 Kaye EC et al. JAMA Network Open.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1001/jamanetworkopen.2021.20925
• Title of Journal or Parent Work: JAMA NETWORK OPEN
• Volume: 4
• Issue: 8
• Start Page: e2120925
• End Page: e2120925
• Grant/Funding Information: Dr Lemmon receives salary support through award K23NS116453 from the National Institute of Neurological Disorders and Stroke.; This work was supported by a Career Development Award from the National Palliative Care Research Center to Dr Kaye and by the American Lebanese Syrian Associated Charities.
• Keywords: PATIENT-ONCOLOGIST ALLIANCE; General & Internal Medicine; Science & Technology; CHILDREN; Medicine, General & Internal; Life Sciences & Biomedicine
• Research Categories: Health Sciences, Oncology

Abstract

Importance: Therapeutic alliance is a core component of patient- and family-centered care, particularly in the setting of advancing cancer. Communication approaches used by pediatric oncologists to foster therapeutic alliance with children with cancer and their families are not well understood. Objectives: To identify key oncologist-driven facilitators associated with building and sustaining therapeutic alliance in the setting of advancing pediatric cancer and to develop a framework to guide clinical practice and future investigation of therapeutic alliance. Design, Setting, and Participants: In this qualitative study, serial disease reevaluation discussions that occurred in the clinic, inpatient hospital, or off campus via telephone were recorded among pediatric oncologists, patients with high-risk cancer, and their families across 24 months or until death, whichever occurred first, from 2016 to 2020. This analysis focused on recorded discussions for pediatric patients who experienced progressive disease during the study period. Content analysis was conducted across recorded dialogue to derive inductive codes and identify themes. Participants were patient-parent dyads for whom a primary oncologist projected the patient's survival to be 50% or less, all family members and friends who attended any of their recorded disease reevaluation conversations, and their oncologists and other clinicians who attended the recorded discussions. Results: A total of 33 patient-parent dyads were enrolled and followed longitudinally. From this cohort, 17 patients experienced disease progression during the study period, most of whom were female (11 [64.7%]) and White (15 [88.2%]) individuals. For these patients, 141 disease reevaluation discussions were audio recorded, comprising 2400 minutes of medical dialogue. Most children (14 [82.4%]) died during the study period. A median of 7 disease reevaluation discussions per patient (range, 1-19) were recorded. Content analysis yielded 28 unique concepts associated with therapeutic alliance fostered by oncologist communication. Ultimately, 7 core themes emerged to support a framework for clinician approaches associated with optimizing therapeutic alliance: human connection, empathy, presence, partnering, inclusivity, humor, and honesty. Conclusions and Relevance: In this qualitative study, pediatric oncologists used diverse communication approaches associated with building and deepening connections across advancing illness. These findings offer a framework to support clinical and research strategies for strengthening therapeutic alliance among pediatric oncologists, patients, and families.